Assertive Community Treatment
Assertive Community Treatment (ACT) is an evidence-based treatment model designed to serve people with serious and persistent mental illnesses. ACT provides ongoing treatment and support services that are individualized and very flexible, delivered in a client’s home or in other community settings. Services are intensive and the ratio of staff to clients is usually between 1:10 and 1: 15. A multidisciplinary care team delivers services including individual and group therapy, life skills training, and supported employment. ACT clients spend significantly less time in hospitals and more time in independent living situations, have less time unemployed, earn more income from employment, experience more positive social relationships, express greater satisfaction with life, and are less troubled by symptoms of mental illnesses. The ACT model has been adapted to serve people with serious mental illness who are experiencing homelessness and may be linked to housing assistance, often using scattered-site models of permanent supportive housing. The combination of ACT and housing assistance is more effective than ACT alone or other models of case management.
Problem or Challenge:
Many people with serious mental illness who experience homelessness are not engaged or willing to participate consistently in treatment services that are delivered in clinic settings or highly-structured programs. Often the symptoms of untreated mental illness and co-occurring substance use problems lead to crises that result in hospitalizations or contact with the criminal justice system. Without adequate support, people with serious mental illness may be unable to navigate the systems that provide housing assistance or unable to achieve housing stability if housing is offered.
ACT is a service-delivery model that provides comprehensive, community-based treatment and supports for people with serious and persistent mental illnesses. ACT differs from some other programs that offer linkage or brokerage case management services that refer individuals to mental health, housing, or rehabilitation agencies or services. Instead ACT multidisciplinary staff members work as a team, providing highly individualized services directly to consumers. The ACT team works collaboratively to deliver most of the treatment, rehabilitation, and support services each client needs to live in the community. ACT goes to the consumer whenever and wherever needed and services are available 24 hours a day, seven days a week, 365 days a year. The consumer is not required to adapt to prescriptive rules of a treatment program.
ACT teams include members who are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation and have the competencies and skills to meet a client's multiple treatment, rehabilitation, and support needs. A psychiatrist is a team member, not a consultant to the team. The consumer is a client of the team, not of an individual staff member. ACT strives to lessen or eliminate the debilitating symptoms of mental illness each individual client experiences and to minimize or prevent recurrent acute episodes of mental illness, to meet basic needs and enhance quality of life, to improve functioning in adult social and employment roles, to enhance an individual's ability to live independently in his or her own community, and to lessen the family's burden of providing care.
ACT services include individual supportive therapy, mobile crisis intervention, integrated substance abuse counseling, and psychopharmacologic treatment including prescribing and helping clients manage atypical antipsychotic and antidepressant medications. ACT teams provide more intensive support during times of acute crises and they often work to help clients avoid or shorten periods of hospitalization. Rehabilitation consists of behaviorally-oriented skill teaching (supportive and cognitive behavioral therapy), including structuring time and handling activities of daily living, supported employment, both paid and volunteer work, and support for resuming education. Support services include support, education, and skill teaching to family members, collaboration with families and assistance to clients with children, direct support to help clients obtain legal and advocacy services, financial support, money-management services, and transportation.
ACT services for people experiencing homelessness also include linkages to housing assistance, which is often provided through vouchers or tenant-based rental assistance that can be used for scattered-site supportive housing. ACT teams often include a housing specialist who assists clients with the housing application process. The ACT team may cultivate relationships with landlords and property managers to develop a pool of housing options and work with clients to identify their needs and preferences for housing. Housing specialists or other ACT team members assist clients in negotiating rental agreements and communicating with landlords and neighbors to solve problems and avoid situations that could lead to the loss of housing.
The ACT model is designed to serve adults (including youth and seniors) who have a severe and persistent mental illness causing symptoms and impairments that produce distress and major disability in adult functioning (e.g., employment, self-care, and social and interpersonal relationships). ACT participants usually are people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), or bipolar disorder (manic-depressive illness); those who experience significant disability from other mental illnesses and are not helped by traditional outpatient models; those who have difficulty getting to appointments on their own as in the traditional model of case management; those who have had bad experiences in the traditional system; or those who have limited understanding of their need for help.
Research has demonstrated that ACT offers significant advantages over standard case management models in reducing homelessness, reducing the length and frequency of hospitalizations, and increasing independent living skills among persons with severe mental illness who are homeless (1). ACT also helps to reduce symptoms of mental illness and improve quality of life for participants. For people experiencing homelessness the combination of ACT and housing assistance is more effective than ACT alone.
ACT has been recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) as an Evidence-Based Practice and more information about the results of research about ACT as well as tools to support program implementation can be found in SAMHSA’s Evidence-Based Practices KIT (see below).
An Evidence-Based Practices KIT is available from SAMHSA to provide tools to support the implementation of ACT. The KIT is available in a CD-ROM / DVD version or can be downloaded from the web here.
The National Alliance on Mental Illness created a helpful fact page on their website on ACT. Access it here.
Contact Info for follow-up:
Assertive Community Treatment Association
Evidence-Based Practice: Permanent Supportive Housing
Evidence-Based Practice: Housing First
Model Program: Pathways to Housing
1. Coldwell, Craig M. and William S. Bender. The Effectiveness of Assertive Community Treatment for Homeless Populations with Severe Mental Illness: A Meta Analysis. Am J Physciatry 2007; 164:393-399. http://ajp.psychiatryonline.org/article.aspx?volume=164&page=393